TEST BANK FOR MATERNAL NEWBORN
NURSING THE CRITICAL COMPONENTS
OF NURSING CARE 4th EDITION
CHAPTER 1-19 COMPLETE GUIDE A+
A nurse is caring for a patient who is in the active phase of the first stage of labor. How
often should the nurse monitor fetal heart rate and contractions during this phase?
1. Every 5 to 10 minutes
2. Every 15 to 20 minutes
3. Every 30 to 40 minutes
4. Every 45 to 60 minutes - correct ans-2. Every 15 to 20 minutes
The nurse should monitor fetal heart rate and contractions every 15 to 20 minutes in the
active phase of the first stage of labor.
A woman in labor is dilated 9 cm, effaced 100%, and has contractions that occur almost
every minute and last 90 seconds. She is exhausted and has trouble concentrating. The
nurse recognizes that this woman is in which phase of the first stage of labor?
1. Latent phase
2. Active phase
3. Transitional phase
4. Expulsive phase - correct ans-2. Active phase
The latent phase is the early and slower part of labor with an average length of 9 hours
for primiparous and 5 hours for multiparous women. Women in this phase are talkative
and able to relax with the contractions. Characteristics of this phase are cervical dilation
from 0 to 3 cm with effacement from 0% to 40%, along with contractions occurring every
5 to 10 minutes, lasting 30 to 45 seconds, and being of mild intensity. Women often
describe these contractions as feeling like strong menstrual cramps.
The active phase is characterized by cervical dilation of 4 to 7 cm with effacement of
40% to 80%. Contractions become more intense, occurring every 2 to 5 minutes with a
duration of 45 to 60 seconds. The woman tends to be more serious and fatigued in this
phase and turns inward.
The transition phase is characterized by cervical dilation of 8 to 10 cm with complete
(100%) effacement. Contractions are intense, occur every 1 to 2 minutes, and last 60 to
90 seconds. It is the shortest but most difficult phase of the first stage of labor, and the
woman is typically exhausted and has trouble concentrating.
Expulsive refers to the second stage of labor, not a phase of the first. It involves the
delivery of the baby.
, Early in labor, a patient tells the nurse that she had an awful experience with pain in her
last pregnancy and would like strongest pain relief option available for a vaginal birth.
Which of the following should the nurse suggest to the patient?
1. Parenteral opioids
2. Nitrous oxide
3. Epidural anesthesia
4. General anesthesia - correct ans-3. Epidural anesthesia
Parenteral opioids blunt but do not eliminate pain, and therefore are not the strongest
form of pain relief in labor and delivery.
Nitrous oxide is a combination of oxygen and nitrous oxide gas that is self-administered
by the laboring woman using a mouth tube or face mask, when she determines that she
needs it. As an analgesic, it relieves pain, but does not block it as effectively as an
epidural.
Epidural anesthesia involves placement of a very small catheter and injection of local
anesthesia and/or analgesia between the fourth and fifth vertebrae into the epidural
space. It has the potential of 100% blockage of pain.
General anesthesia is not typically used in vaginal births.
4.Early in labor, a patient tells the nurse that she would like an unmedicated birth, in
general, but would like some pain relief that is fast-acting, that she can administer
hersef, and that will not interfere with the normal physiology and progress of labor.
Which of the following should the nurse suggest to the patient?
1. Parenteral opioids
2. Nitrous oxide
3. Epidural anesthesia
4. General anesthesia - correct ans-1. Parenteral opioids
Parenteral opioids are considered a medication and can cause neonatal respiratory
depression, so they do not meet the criteria of the patient.
Nitrous oxide is a combination of oxygen and nitrous oxide gas that is self-administered
by the laboring woman using a mouth tube or face mask, when she determines that she
needs it. It can be started and stopped at any point during labor, according to the needs
and preferences of the woman. It takes effect in about 50 seconds after the first breath,
and the effect is transient. It is has no adverse effects on the normal physiology and
progress of labor.
Epidural anesthesia involves placement of a very small catheter and injection of local
anesthesia and or analgesia between the fourth and fifth vertebrae into the epidural
space. It involves the administration of a medication and is rather involved to set up, so
it does not meet the criteria of the patient.
General anesthesia is not typically used in vaginal births.
NURSING THE CRITICAL COMPONENTS
OF NURSING CARE 4th EDITION
CHAPTER 1-19 COMPLETE GUIDE A+
A nurse is caring for a patient who is in the active phase of the first stage of labor. How
often should the nurse monitor fetal heart rate and contractions during this phase?
1. Every 5 to 10 minutes
2. Every 15 to 20 minutes
3. Every 30 to 40 minutes
4. Every 45 to 60 minutes - correct ans-2. Every 15 to 20 minutes
The nurse should monitor fetal heart rate and contractions every 15 to 20 minutes in the
active phase of the first stage of labor.
A woman in labor is dilated 9 cm, effaced 100%, and has contractions that occur almost
every minute and last 90 seconds. She is exhausted and has trouble concentrating. The
nurse recognizes that this woman is in which phase of the first stage of labor?
1. Latent phase
2. Active phase
3. Transitional phase
4. Expulsive phase - correct ans-2. Active phase
The latent phase is the early and slower part of labor with an average length of 9 hours
for primiparous and 5 hours for multiparous women. Women in this phase are talkative
and able to relax with the contractions. Characteristics of this phase are cervical dilation
from 0 to 3 cm with effacement from 0% to 40%, along with contractions occurring every
5 to 10 minutes, lasting 30 to 45 seconds, and being of mild intensity. Women often
describe these contractions as feeling like strong menstrual cramps.
The active phase is characterized by cervical dilation of 4 to 7 cm with effacement of
40% to 80%. Contractions become more intense, occurring every 2 to 5 minutes with a
duration of 45 to 60 seconds. The woman tends to be more serious and fatigued in this
phase and turns inward.
The transition phase is characterized by cervical dilation of 8 to 10 cm with complete
(100%) effacement. Contractions are intense, occur every 1 to 2 minutes, and last 60 to
90 seconds. It is the shortest but most difficult phase of the first stage of labor, and the
woman is typically exhausted and has trouble concentrating.
Expulsive refers to the second stage of labor, not a phase of the first. It involves the
delivery of the baby.
, Early in labor, a patient tells the nurse that she had an awful experience with pain in her
last pregnancy and would like strongest pain relief option available for a vaginal birth.
Which of the following should the nurse suggest to the patient?
1. Parenteral opioids
2. Nitrous oxide
3. Epidural anesthesia
4. General anesthesia - correct ans-3. Epidural anesthesia
Parenteral opioids blunt but do not eliminate pain, and therefore are not the strongest
form of pain relief in labor and delivery.
Nitrous oxide is a combination of oxygen and nitrous oxide gas that is self-administered
by the laboring woman using a mouth tube or face mask, when she determines that she
needs it. As an analgesic, it relieves pain, but does not block it as effectively as an
epidural.
Epidural anesthesia involves placement of a very small catheter and injection of local
anesthesia and/or analgesia between the fourth and fifth vertebrae into the epidural
space. It has the potential of 100% blockage of pain.
General anesthesia is not typically used in vaginal births.
4.Early in labor, a patient tells the nurse that she would like an unmedicated birth, in
general, but would like some pain relief that is fast-acting, that she can administer
hersef, and that will not interfere with the normal physiology and progress of labor.
Which of the following should the nurse suggest to the patient?
1. Parenteral opioids
2. Nitrous oxide
3. Epidural anesthesia
4. General anesthesia - correct ans-1. Parenteral opioids
Parenteral opioids are considered a medication and can cause neonatal respiratory
depression, so they do not meet the criteria of the patient.
Nitrous oxide is a combination of oxygen and nitrous oxide gas that is self-administered
by the laboring woman using a mouth tube or face mask, when she determines that she
needs it. It can be started and stopped at any point during labor, according to the needs
and preferences of the woman. It takes effect in about 50 seconds after the first breath,
and the effect is transient. It is has no adverse effects on the normal physiology and
progress of labor.
Epidural anesthesia involves placement of a very small catheter and injection of local
anesthesia and or analgesia between the fourth and fifth vertebrae into the epidural
space. It involves the administration of a medication and is rather involved to set up, so
it does not meet the criteria of the patient.
General anesthesia is not typically used in vaginal births.
